(2) Lecture 11: Foot and Ankle Prolems 1.0 Flashcards
Plantar fascia
Composed of 3 segments: CENTRAL, medial + lateral
- central starts from medial tubercle on plantar surface of calcaneus
- travels towards toes as solid band dividing just before MT heads into 5 slips
helps support foot against downward forces
Most important segment of plantar fascia
Central
Windlass Mechanism
- when toes are extended, plantar fascia functionally shortens and wraps around MT heads
- planta fascia dynamically affects ARCH HEIGHT
- responsible for transferring weight from medial to lateral side of foot during gait
- also important for arch support/shock absorption
Plantar Fasciitis
- most common condition in foot
Caused by overuse or excessive loading
- especially in those w/ atypical arches (Pes Planus + Pes Cavus)
- with active ppl, may be due to changes in training/FITT
- linked to BMI in less active ppl
Plantar Fasciitis - Tissue Level
NOT inflammation
a FASCIOSIS
- OVERUSE condition
- changes in structure (ex. collagen disarray)
- non-inflammatory degenerative condition
Symptoms of Plantar Fasciitis
- gradual onset of pain
- SHARP STABBING PAIN on FIRST steps in morning or after long periods of non-weightbearing
- pain improves after initial few steps but worsens w/ prolonged activity
Signs of Plantar Fasciitis
- Pes Planus or Pes Cavus
- decreased dorsiflexion (tight gastroc/soleus, poor jt mobility)
- weakness of Tib. Post. (plantar flexor)
- pain on palpation over origin of PF (medial side of calcaneus)
Over pronators
Turn IN too far
- have hard time maintaining arch
- trouble w/ resupination = no rigidity
- may cause twist during propulsion
Over supinators
Decreased shock absorption
- decreased ability to adapt to terrain
- due to lack of pronation
- force thru fascia to absorb shock
Role of Pronation in Gait Cycle
Foot function: MOBILE ADAPTER
Foot structure: lowered arches, looser joints
Gait Phase: just after heel strike to foot flat
NOT WANTED AT PROPULSION
Role of Supination in Gait Cycle
Foot Function: RIGID LEVER
Foot structure: heightened arches, tighter joints
Gait Phase: short period at heel strike; foot flat to toe-off
NOT WANTED WHEN LOADING
Tight Posterior Structures
- anatomical connection btwn Achilles tendon and plantar fascia
- if Achilles tendon is tight, plantar fascia may be pulled too tight
Tight plantar flexors affects dorsiflexion ROM and will affect motion
Heel Spurs
- in 80% of plantar fasciitis patients
- due to REPETITIVE MICROTRAUMA
- spur length is correlated w/ age, BMI, symptom duration + perceived pain
Treatment of Plantar Fasciitis
Initial Pain Control
Taping
- over pronators - acute < 10 days
Orthotics - over the counter vs custom < 1year
Night splints
- for symptoms > 6 months
Treatment of Plantar Fasciitis
Fibroblastic/Repair
- correct training errors
Manual therapy/soft tissue work and exercise
- cavus foot
- tight posterior muscles
Stretching
- tight posterior muscles
- plantar fascia
Treatment of Plantar Fasciitis
Late Repair/Remodeling
- idealize strength
- add in power + agility (push off, jumping, cutting)
- decide on return to play: taping, shoes or insole
Morten’s Neuroma
- not a true neuroma
- compressive neuropathy of COMMON PLANTAR DIGITAL NERVE of 3rd webspace
- nerve is thickest from medial plantar nerve and lateral plantar nerve
Transverse arch anatomy
good transverse arch = more space for nerves
decreased transverse arch = less space for nerves as bones drop
- causes inflammation from mechanical irritation
Symtpoms of Morten’s Neuroma
Pain/burning into
- plantar aspect of forefoot
- toes
Made worse by forefoot weight-bearing
- dancing, high heeled shoes
Might describe as working over a stone/pebble
Signs of Morten’s Neuroma
Squeeze test
- examiner compresses forefoot w/ hand, while squeezing web space
- webspace tenderness
- plantar percussion (Tinel’s test) - tap test
- toe-tip numbness
Treatment of Morten’s Neuroma
Acute and inflamed
- Police/Peace & Love
- refer for corticosteroid injection
Chronic or after acute phase
- avoid high-heeled, pointed or narrow shoes
- select shoes w/ wide toe box
- avoid aggravating activities
Correction of transverse flatfoot
- mobilization of foot (splaying to increase transverse arch position)
- metatarsal pad = raises arch
Last Resort for Morten’s Neuroma
Surgical
- inter-metacarpal ligament cut
- nerve transsected
Sesamoiditis
- two sesamoids beneath 1st MTP jt to protect flexor hallicus longus from being crushed
- transmit forces from ground to 1st MT head
- often caused by repetitive stress and/or hyperextension of great toe
Most common in dancing + basketball
Symptoms of Sesamoiditis
- pain under great toe/forefoot when weight bearing
- improved when not weight bearing
- worse w/ dorsiflexion of great toe
Signs of Sesamoiditis
- swelling, redness
- pain w/ passive dorsiflexion of great toe
- pain and weakness w/ resisted plantar flexion
- pain w/ direct palpation of medial or lateral sesamoid
Treatment of Sesamoiditis
Treatment of “ITIS”
Inflammatory/Destructive Phase
- POLICE/Peace&Love
- restrict activity to allow inflammation to subside
- metatarsal bar, dancers pad or orthotics
Prior to return to play
- correct training errors
Turf Toe
- can be one time or repetitive trauma
- MOI: posterior roll-up
- forced hyperextension of great toe (dorsiflexion > 100 degrees) = tear of plantar capsule + plantar ligaments of great toe
Predisposing factors
- playing on artificial turf
- soft flexible footwear
Symptoms of Turf Toe
- hyper dorsiflexion of great toe
- pain swelling and at first MTP jt
- worse w/ movement + weight-bearing
- weak “push-off”
Signs of Turf Toe
- visible swelling, redness, ecchymosis
- pain w/ passive plantar and dorsiflexion of great toe
- pain + weakness w/ resisted plantar flexion of great toe
- pain + laxity w/ dorsoplantar drawer test
Treatment of Toe Turf
Inflammatory/Destructive Phase
- POLICE/PEACE&LOVE
- crutches and/or tape to protect
Before end of this stage
- optimize healing environment
- palliate pain
- decrease swelling
Treatment of Toe Turf
Repair/Fibroblastic
Protect tissue and idealize healing environment
- increase blood flow = heat
Before end of this stage
- idealize ROM
- progress weight-bearing
- begin gentle strengthening
Treatment of Toe Turf
Remodeling Stage
Functional training for return to play
- idealize strength thru range
- add in power + agility (push-off, jumping, cutting, etc)
- decide on return to play taping, shoes and/or ridged insole
